Asymptomatic HTN

[DocEspana]

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btw in february or march of this year ACEP changed the recommendations in a really subtle way. They previously used to say that you didn't need to start any new meds, just pass it off the PCP (and if you read the FULL report a lot of that is that since blood work isnt necessary on these patients but blood work IS needed to start any med except ccbs, just dont start meds so you dont have to draw blood). Now they say that we *should* start meds and/or increase current dosages if the reason is not noncompliance or just pain/anxiousness. They still make it very clear that there is no goal BP or any "dangerous" BP to act differently over. They are just making day zero of new treatment be the ED visit.

I have no problem with the recommendations.

I have a problem with them taking down (and completely wiping the internet of) their old recommendations which had SUCH a good patient-friendly summary of the "dont test, don't treat, don't worry' mantra. Now they only have the overly-dense medical version of the new guidelines.

 

[DocEspana]

You guys actually bother trying to educate other doctors on why it's pointless to send them in?

One of our PCP's sent in a woman who was ~200/100. No symptoms but apparently there were EKG changes. I looked at them and they were subtle STD or even non-existent. One of those kinds that you can barely see. I tried letting the PCP know there isn't much for us to do, and even said our national guidelines write to not treat and to let outpatient doctors treat. She was an outpatient doctor and sent her in anyway.

I don't even know if it's worth it these days.

I'm sure everyone else has said it, but you can't educate the PCPs. Not that its impossible but that 51% of those referrals are actually coming from their triage nurse, waiting room receptionist, or answering service, not the PCP. 44% are coming from physicians who "have been practicing this way for years and nothing bad has happened yet" and are closed to the idea of changing their patterns. About 5% actually sent them over for some other reason but the patient is too fixated on the BP to even know why they got sent.

 

[thegenius]

btw in february or march of this year ACEP changed the recommendations in a really subtle way. They previously used to say that you didn't need to start any new meds, just pass it off the PCP (and if you read the FULL report a lot of that is that since blood work isnt necessary on these patients but blood work IS needed to start any med except ccbs, just dont start meds so you dont have to draw blood). Now they say that we *should* start meds and/or increase current dosages if the reason is not noncompliance or just pain/anxiousness. They still make it very clear that there is no goal BP or any "dangerous" BP to act differently over. They are just making day zero of new treatment be the ED visit.

I have no problem with the recommendations.

I have a problem with them taking down (and completely wiping the internet of) their old recommendations which had SUCH a good patient-friendly summary of the "dont test, don't treat, don't worry' mantra. Now they only have the overly-dense medical version of the new guidelines.

You referring to this?

https://www.acep.org/siteassets/sites/acep/media/clinical-policies/final-cp-pdfs/asxhypertension-cp.pdf

 

[DocEspana]

You referring to this?

https://www.acep.org/siteassets/sites/acep/media/clinical-policies/final-cp-pdfs/asxhypertension-cp.pdf

Yup. The old page where they had a similar formal paper AND a simplified "two questions you need to know" based on the 2013 recommendations is gone. Which I understand based on them having new recommendations. But I really wish they left the old page because that "two questions you need to know" would need only the slightest modification to still be accurate and was so useful for reassuring patients that their asymptomatic htn is fine.

 

[southerndoc]

I think we do these people a disservice when we don't start antihypertensives. Most people can't see a PCP for an initial visit for at least six months.

 

[VA Hopeful Dr]

I think we do these people a disservice when we don't start antihypertensives. Most people can't see a PCP for an initial visit for at least six months.

So you're giving them 6 months of medication when you discharge them?

 

[WhatJobDoIPick]

I think we do these people a disservice when we don't start antihypertensives. Most people can't see a PCP for an initial visit for at least six months.

I give a month of Losartan. No reason not to.

 

[turkeyjerky]

So you're giving them 6 months of medication when you discharge them?

30 days of meds, but tell pt to check their BP 3x per day and “only use ‘em if you need ‘em!”

 

[WhatJobDoIPick]

30 days of meds, but tell pt to check their BP 3x per day and “only use ‘em if you need ‘em!”

I send home with radial art line in place for real time monitoring

 

[BoardingDoc]

I send home with radial art line in place for real time monitoring

Pfft. Baby. I just throw a 20cc bottle of hydralazine in a bag with a bunch of syringes and needles and send them on their way. People are smart. They'll figure it out.

 

[RustedFox]

Pfft. Baby. I just throw a 20cc bottle of hydralazine in a bag with a bunch of syringes and needles and send them on their way. People are smart. They'll figure it out.

Pfft. Baby. I prescribe PRE-arrival meds to RAISE their asymptomatic HTN for the gainz.

 

[BoardingDoc]

 

[RustedFox]

View attachment 408824

This got me to laugh hard in the middle of the gym.

 

[southerndoc]

So you're giving them 6 months of medication when you discharge them?

Yes

 

[DocEspana]

I think we do these people a disservice when we don't start antihypertensives. Most people can't see a PCP for an initial visit for at least six months.

which is why ACEP changed their recommendations from "accidentally overtreating is a real thing, so maybe think twice before starting new meds" to "just start them on something if they have nothing."

My (huge, flashing, and flaming) concern is that htn is not supposed to be diagnosable by the standard criteria on a single elevated measurement or on those who are sick/in pain for the most part. So we are really *still* running afoul of the concern ACEP had from 2013 until earlier this year - that we might be starting a daily medication for a temporary BP rise and leading to iatrogenic hypotension. But I do trust, especially after reading their reasoning on it, that starting meds is more benefit than harm for most people and assume we can use some common sense to feel out where the patterns for 'this is temporary' vs 'this is htn' exist.

 

[thegenius]

which is why ACEP changed their recommendations from "accidentally overtreating is a real thing, so maybe think twice before starting new meds" to "just start them on something if they have nothing."

My (huge, flashing, and flaming) concern is that htn is not supposed to be diagnosable by the standard criteria on a single elevated measurement or on those who are sick/in pain for the most part. So we are really *still* running afoul of the concern ACEP had from 2013 until earlier this year - that we might be starting a daily medication for a temporary BP rise and leading to iatrogenic hypertension. But I do trust, especially after reading their reasoning on it, that starting meds is more benefit than harm for most people and assume we can use some common sense to feel out where the patterns for 'this is temporary' vs 'this is htn' exist.

I'm not entirely opposed to starting or adjusting their meds. But for many of the reasons you write above I tend not to do it. It's a case-by-case basis and I suspect I do it less than the average ER doc. I certainly don't give an Rx for 6 months. That may not even be standard of care in the PCP office if you are starting someone on HTN medicine for the first time.

Just yesterday UC sent in an asymptomatic woman who was 200/100. They had the good sense to give clonidine 0.1 mg (should have been 0.2 mg) and wait like 30 minutes, and the BP went down to 185. After my history I restarted her two BP meds she has been on in the past that she stopped taking.

 

[southerndoc]

which is why ACEP changed their recommendations from "accidentally overtreating is a real thing, so maybe think twice before starting new meds" to "just start them on something if they have nothing."

My (huge, flashing, and flaming) concern is that htn is not supposed to be diagnosable by the standard criteria on a single elevated measurement or on those who are sick/in pain for the most part. So we are really *still* running afoul of the concern ACEP had from 2013 until earlier this year - that we might be starting a daily medication for a temporary BP rise and leading to iatrogenic hypotension. But I do trust, especially after reading their reasoning on it, that starting meds is more benefit than harm for most people and assume we can use some common sense to feel out where the patterns for 'this is temporary' vs 'this is htn' exist.

I usually prescribe, but tell them to take their BP at home or with a friend's machine. If it remains >140/90, then start the medication.

 

[DocEspana]

I usually prescribe, but tell them to take their BP at home or with a friend's machine. If it remains >140/90, then start the medication.

In the last year, I moved from an inner city, largely Haitian, community to a a suburban largely affluent community.

The adjustment has been rough. Going from blood pressure values that seem incompatible with nephron survival being their everyday functional status, to people checking their BP q15 minutes for 6 hours and wondering why they went from 131/65 (that's high for me, doc) to 175/66 with each check is an adjustment.

I wish I could prescribe the former new kidneys and the latter new brains.

 

[Zebra Hunter]

I'm not entirely opposed to starting or adjusting their meds. But for many of the reasons you write above I tend not to do it. It's a case-by-case basis and I suspect I do it less than the average ER doc. I certainly don't give an Rx for 6 months. That may not even be standard of care in the PCP office if you are starting someone on HTN medicine for the first time.

Just yesterday UC sent in an asymptomatic woman who was 200/100. They had the good sense to give clonidine 0.1 mg (should have been 0.2 mg) and wait like 30 minutes, and the BP went down to 185. After my history I restarted her two BP meds she has been on in the past that she stopped taking.

“Good sense”. People need to stop giving clonidine to patients with hypertension. It’s essentially never appropriate and drives me up a wall when I see my anxiety, hypertensive patients on PRN clonidine. Its duration of action is ~4 hours and can potentially cause rebound hypertension.

 

[RustedFox]

“Good sense”. People need to stop giving clonidine to patients with hypertension. It’s essentially never appropriate and drives me up a wall when I see my anxiety, hypertensive patients on PRN clonidine. Its duration of action is ~4 hours and can potentially cause rebound hypertension.

I'm not sure I believe the four-hour duration of action. I take it for sleep. 0.3, and my muscles just "quit" and really won't work the next day at the gym. I learned not to do that if I want to lift.